Nursing Care Plan Stress overload Definition:Irreversible, long-standing, and/or progressive deterioration of intel-lect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation,and behavior, is a professional judgment based on the application of clinical knowledge which determines potential or actual experiences and responses to health problems and life processes. The list of nanda nursing diagnosis can be applied to individuals, families or communities. Included with the list of nanda nursing diagnosis is an array of commonly applied interventions from which the caregiver can choose to implement to the given patient. Standardized nursing language is a body of terms used in the profession that is considered to be understood in common. The use of common terms promotes patient safety by allowing nurses to quickly and efficiently understand the aspects of a patient’s needs. The use of standardized terms allows nursing staff to avoid sifting through long narratives in order to determine a particular patient’s needs and planned course of care. Nursing Care Plan Stress overload
- Altered interpretation, response to stimuli, and/or personality
- No change in LOC
- Clinical evidence of organic impairment
- Short- and long-term memory loss
- Progressive or long-standing impaired cognition or socialization
- Alzheimer’s disease
- Korsakoff’s psychosis
- Cerebral vascular accident
- Multi-infarct dementia
- Head injury
Expected Outcomes The Patient Will
- Remain free of injury caused by confusion.
- Exhibit no signs of depression.
- Maintain weight.
- Have an environment structured for maximum functioning.
- Participate in selected activities to fullest extent possible.
- Receive adequate emotional support.
Family Members Will
- Discuss strategies to provide care and help patient cope.
- Maintain safety of patient’s home environment.
- Receive information on the options available for long-term care.
- Assist patient to prepare for relocation to long-term care facility.
Suggested Noc Outcomes
Client Satisfaction: Safety; Cognition; Cognitive Orientation
Interventions And Rationales
Determine: Assess patient’s cognitive abilities and changes in behav-ior to provide baseline data.Weigh patient and include instructions for regular weighing as part of care plan to monitor patient’s nutritional status.Perform: Take steps to provide a stable physical environment and consistent daily routine for patient. Stability and consistency enhancefunctioning.69 Inform: Teach family members or caregiver strategies to help patient cope with his condition: Place an identiﬁcation bracelet on patient to promote safety; touch patient to convey acceptance; avoid unfamiliarsituations when possible to help ensure consistent environment; provide structured rest periods to prevent fatigue and reduce stress; refrain from asking questions patient can’t answer to avoid frustration; provide ﬁnger foods if patient won’t sit and eat to ensure adequate nutrition;select activities based on patient’s interests and abilities and praise him or her for participating in activities to enhance his or her sense of self-worth; use television and radio carefully to avoid sensory overload;limit choices patient has to make to provide structure and avoid confu-sion; label familiar photos to provide a sense of security; use symbols,rather than written signs, to identify patient’s room, bathroom, and other facilities to help patient identify surroundings; place patient’s name in large block letters on clothing and other belongings to help him recognize his belongings and prevent them from becoming lost.Attend: Encourage family members to watch mental status assessments to provide a more accurate view of patient’s abilities.Evaluate patient’s ability to perform self-care activities, including ability to function alone and drive a car. Safety is a primary concern.Ask family members about their ability to provide care for patient to assess the need for assistance.Project an attentive, nonjudgmental attitude when listening to them to help ensure that you receive accurate information.Manage: Assist family members in contacting appropriate community services. If necessary, act as an advocate for patients within health-care system to help secure services needed for ongoing care.Provide family members with information concerning long-term healthcare facilities. If patient is to be moved to a long-term care facility, explain the decision to him in as simple and gentle terms as possible to facilitate comprehension.Allow patient to express feelings regarding the move to facilitate grieving over loss of independence. Provide psychological support to patient and family members to alleviate stress they may experienceduring relocation.Communicate all aspects of discharge plan to staff members at patient’s new residence. Documenting a discharge plan and commu-nicating it to caregivers help ensure continuity of care. Interventions should ensure patient’s dignity and rights.
Suggested Nic Interventions
Cognitive Stimulation; Dementia Management; Family Involvement Promotion; Reality Orientation
Rader, J., et al. (2006, April). The bathing of older adults with dementia.American Journal of Nursing, 106(4), 40–48.